Is alcohol negatively affecting your job/career?
Yes
No
Please describe your job/career?
What is your biggest concern you have with your drinking?
My Health
I will lose everything
I will lose my family
I will lose my identity
I will lose my job
I will continue to embarrass myself
I will die
If I stop, what will my life be like?
What do you want to do about your relationship with alcohol?
Quit completely
Gain control
Do nothing
What's your First Name?
What's your Last Name?
What is the best email to contact you at?
What is the best number to contact you at?
Right now, I _________
have the financial resources to invest in mentoring
have access to financial resources to invest in mentoring
don't have the financial resources or access to them
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